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Critical Access Hospitals

Last updated 10/7/08, 2:46 p.m. CT


Comprehensive Accreditation Manual for Critical Access Hospitals (CAMCAH)

   
The Updates
The Accreditation Process
Sentinel Events
National Patient Safety Goals
The Joint Commission Quality Report
Accreditation Participation Requirements (APRs)
Standards, Rationales, Elements of Performance, and Scoring
 Section 1: Patient-Focused Functions
  Ethics, Rights, and Responsibilities (RI)
  Provision of Care, Treatment, and Services (PC)
  Medication Management (MM)
  Surveillance, Prevention, and Control of Infection (IC)
 Section 2: Organization Functions
  Improving Organization Performance (PI)
  Leadership (LD)
  Management of the Environment of Care (EC)
  Management of Human Resources (HR)
  Management of Information (IM)
 Section 3: Structures with Functions
  Medical Staff (MS)
  Nursing (NR)
Performance Measurement and the ORYX Initiative
Simplifying Compliance Activities


The Updates

2007 Update 1 Table of Changes

2007 Update 2 Table of Changes

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The Accreditation Process

2008 Accreditation Decision Rules for All Programs (8/07)

2008 Thresholds for Conditional Accreditation/Certification and Preliminary Denial of Accreditation/Certification (12/07)

Clarification on Details of Elimination of Four-Month Track Record Requirements Decision (1/08)

Methodology for Conducting Unannounced Surveys Within an 18-39 Month Window (4/08)

Inclusion of a Clarification Validation Survey as Part of the Appeal Process (5/08)

Time Limits Approved for Organizations to Eliminate an Immediate Threat to Life Situation (5/08)

Improvements to the Decision Process (8/08)

10-Day Clarification Time Frame (8/08)

2009 Accreditation Decision Rules (8/08)

Correction to Accreditation Decision Rule CON02 (9/08)

Critical Access Hospital Program Policy Changes (9/08)

How SII May Affect Your PPR (10/08)

Modifications to the Electronic Statement of Conditions™ for States Requiring Suspension of Testing Activities (10/08)

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Sentinel Events

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National Patient Safety Goals

The 2008 National Patient Safety Goals (7/07)

The Joint Commission Announces the 2009 National Patient Safety Goals and Requirements (7/08)

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The Joint Commission Quality Report

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Accreditation Participation Requirements (APRs)

The Joint Commission Suspends Standard MS.1.20 Implementation Date; Implementation Task Force to Continue Work on Medical Staff Standard Revision (7/08)

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Standards, Rationales, Elements of Performance, and Scoring

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Section 1: Patient-Focused Functions

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Ethics, Rights, and Responsibilities (RI)

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Provision of Care, Treatment, and Services (PC)

Correction to Standard PC.2.120, EP 2 (12/07)

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Medication Management (MM)

Standard MM 4.10, EP 1 in the Emergency Department—Interim Action Suspended Effective Immediately (7/07)

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Surveillance, Prevention, and Control of Infection (IC)

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Section 2: Organization Functions

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Improving Organization Performance (PI)

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Leadership (LD)

Revisions to Contracted Services Standard LD.3.50 (7/07)

Correction to LD.3.50, EP 9 (2/08)

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Management of the Environment of Care (EC)

Correction to Rationale for Standard EC.4.16 (11/07)

Correction to Standard EC.4.20, EP 4 (11/07)

Revision to Note for Standard EC.4.12, EP 6 (1/08)

Revisions to Fire-Safety Equipment Maintenance Standard EC.5.40, EP 14 (1/08)

Change in Compliance Expectation for Emergency Management Standards (6/08)

Modifications to the Electronic Statement of Conditions™ for States Requiring Suspension of Testing Activities (10/08)

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Management of Human Resources (HR)

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Management of Information (IM)

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Section 3: Structures with Functions

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Medical Staff (MS)

Revisions to Standard MS.1.20 (9/07)

Correction to Standard MS.1.20 Effective Date (10/07)

Correction to MS.4.30, EP 1 (4/08)

The Joint Commission Suspends Standard MS.1.20 Implementation Date; Implementation Task Force to Continue Work on Medical Staff Standard Revision (7/08)

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Nursing (NR)

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Performance Measurement and the ORYX Initiative

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Simplifying Compliance Activities

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